Tuesday, February 12, 2013

An article* published this
month in JAMA reports that in
patients with unilateral lateral epicondylalgia, corticosteroid injections were
associated with poorer long-term outcomes and higher recurrence rates than
other interventions 1 year after receiving the injection. Patients in the same
study who participated in 8 weeks of multimodal
physical therapy did not achieve long-term outcomes. However, physical therapy
was beneficial in the short term in the absence of corticosteroid injection. In
addition, significantly fewer patients receiving physical therapy consumed an
analgesic or anti-inflammatory medication.

This
randomized, injection-blinded, placebo-controlled
trial was conducted in Australia at a single university research center and 16
primary care settings. A total of 165 patients aged 18 years or older with
unilateral lateral epicondylalgia of longer than 6 weeks' duration were
enrolled between July 2008 and May 2010; 1-year follow-up was completed in May
2011.

Of the 165 patients, 43 received corticosteroid injection,
41 received placebo injection, 40 received corticosteroid injection plus
physical therapy, and 41 received placebo injection plus physical therapy. The
physical therapy intervention was standardized, based on current evidence, and
primarily included manual therapy and exercise. The exercise program included
twice daily sensorimotor retraining of gripping and concentric and eccentric
exercise to progressively load the wrist extensors using resistive elastic
latex bands. The patients' home program and exercise diaries were monitored to
facilitate program adherence.

The 2 primary
outcomes were 1-year global rating of change scores for complete recovery or
"much improvement" and 1-year recurrence (defined as complete
recovery or much improvement at 4 or 8 weeks but not later) analyzed on an
intention-to-treat basis. Secondary outcomes included complete recovery or much
improvement at 4 and 26 weeks.

At 1 year,
corticosteroid injection demonstrated lower complete recovery or much
improvement and greater recurrence compared with placebo injection. There were
no differences between physical therapy and no physical therapy for complete
recovery or much improvement or recurrence.

In
their analysis of secondary outcomes, the authors found that at 4 weeks there
was a significant interaction between corticosteroid injection and physical
therapy for complete recovery or much improvement. In particular, patients who
received the placebo injection plus physical therapy had greater complete
recovery or much improvement compared with patients who did not receive
physical therapy, and medium-sized benefits for worst pain, resting pain, and
pain and disability.

Despite
their finding that physical therapy did not provide a statistically significant
long-term effect on complete recovery compared with the other groups, the
authors say that physical therapy "should not be dismissed altogether,"
because in the absence of corticosteroid it provided short-term benefit across
all outcomes and had the highest percentage of participants reporting a
complete recovery or improvement at 1 year.

The
results of this study were widely reported in the mainstream media, including
articles by USA Today, The New York Times, ABC News, NPR, and CBS News.

* The
full text of this study is available by subscription or purchase only.
Copyright protections prohibit APTA from disseminating the information. For
suggestions about obtaining literature, visit APTA's Finding Information in Physical Therapy Literature webpage.

Comments

Thanks for correctly highlighting that this study does in fact suggest a net benefit to using physiotherapy in treating tennis elbow. I have seen a number of erroneous health headlines in reference to this paper that suggest physiotherapy is no better than doing nothing to treat this condition - a conclusion which is not supported by the data presented in the study.
It's important to note that not only did patients receiving physiotherapy exhibit significant improvement earlier than those that did not (the physiotherapy group demonstrated statistically significant improvements at 4 weeks of treatment)and had the most ideal outcomes, they also had the lowest rate of recurrence. Perhaps even more important to note, the authors of this study narrowly define 'physiotherapy' as "manual elbow therapy and exercise", and provided ALL participants in the study with education on pain avoidance, analgesics and anti inflammatories, braces, use of heat/cold, etc. Such education is obviously a central component of any physiotherapy program, and as such it is not surprising to me that patients in the "no-physiotherapy" group eventually got better on their own.
If you're interested, I wrote my own review of this clinical study here: http://www.torontophysiotherapy.ca/rehab-science-blog/physiotherapy-for-tennis-elbow/
Best,
Ryan

Posted by Ryan Davey
on 2/13/2013 9:54 AM

Thanks for posting and I agree with what Ryan has posted. The other important aspect to note is that it is very difficult to standardize a manual therapy, hands-on soft tissue technique because each patient has an individualized problem that is not best solved by a protocol or cook book method, which unfortunately is what has to be used in a RCT.